Healthcare Provider Details

I. General information

NPI: 1497193882
Provider Name (Legal Business Name): LATONYA ROCHELLE CONNALLY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11447 JOS CAMPAU ST
HAMTRAMCK MI
48212-3040
US

IV. Provider business mailing address

325 MOROSS RD
GROSSE POINTE FARMS MI
48236-2911
US

V. Phone/Fax

Practice location:
  • Phone: 313-365-1368
  • Fax:
Mailing address:
  • Phone: 313-886-3870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704270676
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4704270676
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number4704270676
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: